Because of growing safety concerns, Arizona Medicaid staff needed external, validated research to support denials of patient requests for VBAC services at small hospitals. As a result of participating in the Medicaid Medical Directors Learning Network, an AHRQ Knowledge Transfer project, Arizona Medicaid staff members were familiar with the AHRQ evidence report, which suggests that while a VBAC may be a safe alternative at large hospitals with practiced obstetricians, on-call anesthesiologists, and experienced emergency care teams, the research is less clear about alternative clinical environments, such as rural hospitals.

Marc Leib, MD, JD, chief medical officer for AHCCCS and member of the Learning Network, says that the research in the evidence report was very timely. Leib and his colleagues had seen the maternal and perinatal mortality rates associated with VBAC in rural hospitals that often lack appropriate physician coverage. Using the AHRQ report and guidelines from the American Congress of Obstetricians and Gynecologists, AHCCCS implemented a policy for denial of VBAC services unless the services were provided in appropriate clinical settings.

Because patient safety is of primary importance, Medicaid officials are looking for unbiased evidence to support eliminating procedures that have questionable safety standards. Leib elaborates, "AHRQ always has the literature I need to infuse clinical discussions with rigorous, up-to-date science that informs our thinking."